Cognitive Behavioral Therapy (CBT) for Multiple Sclerosis
Health Problem : Cognitive disorders
Designation
Cognitive Behavioral Therapy (CBT) for Multiple Sclerosis
Abbreviation
CBT-MS
Category
Psychosocial
Main Indication
To reduce psychological stress and symptoms of anxiety and depression in people with multiple sclerosis.
How does it work?
- Improvement in anxiety
- Improvement in depressive symptoms
- Proven effectiveness in treating these depressive symptoms through remote care
Other Benefits
- Sustained reduction in perceived fatigue.
- Improved coping strategies for stress.
- Improved adjustment or adaptation to the illness.
- Reduction in stress-related hospitalizations.
- Improved social functioning.
- Improvement in migraine symptoms in some patients.
- For patients on medication, improved adherence to their medication regimen throughout the course of treatment.
- Improved quality of life.
- Improved coping strategies for stress.
- Improved adjustment or adaptation to the illness.
- Reduction in stress-related hospitalizations.
- Improved social functioning.
- Improvement in migraine symptoms in some patients.
- For patients on medication, improved adherence to their medication regimen throughout the course of treatment.
- Improved quality of life.
Direct Risks
A temporary increase in emotional distress may occur when exposed to the source of stress.
Risks of interaction
No adverse effects have been observed with long-term treatments for multiple sclerosis.
Target Audience
Adults with multiple sclerosis experiencing mild to moderate psychological distress.
Contraindications
Severe cognitive impairments that prevent active participation.
Unstabilized psychotic disorders.
Unstabilized psychotic disorders.
Duration
10 weeks
Sessions per week
1 session per week
Precautions
- Indicate your level of fatigue before each session.
- Precautions to take in the event of active relapses of multiple sclerosis.
- Report any new or increased emotions during exposure exercises.
- Precautions to take in the event of active relapses of multiple sclerosis.
- Report any new or increased emotions during exposure exercises.
Regulatory provisions
This practice is reserved for trained clinical psychologists and psychiatrists.
Main Initiator
Aaron T. Beck, University of Pennsylvania, États-Unis.
Author(s) of the Sheet
NPIS (comité scientifique)
Creation Date : 13/03/2026
Revision Date : 01/04/2026
Version : V01
Revision Date : 01/04/2026
Version : V01
Download the sheet in PDF format
Designation
Cognitive Behavioral Therapy (CBT) for Multiple Sclerosis
Abbreviation
CBT-MS
Category
Psychosocial
Main Health benefit
To reduce psychological stress and symptoms of anxiety and depression in people with multiple sclerosis.
Explanation
- Improvement in anxiety (Mohr, 2001; Moss-Morris, 2012; Abbie 2024; Scandiffio 2025)
- Improvement in depressive symptoms (Hind 2014; Abbie 2024; Bruno 2025).
- Best-demonstrated efficacy (Scandiffio 2025)
- Demonstrated efficacy on depressive symptoms in remote settings (Gold 2024).
Routine Test
Hospital Anxiety and Depression Scale (HADS).
Fatigue Severity Scale (FSS).
Fatigue Severity Scale (FSS).
Threshold
Hospital Anxiety and Depression Scale HADS-A or HADS-D ≥ 11.
Fatigue Severity Scale FSS ≥ 4.
Fatigue Severity Scale FSS ≥ 4.
Minimal Clinically Important Change
A reduction of at least 30% in HADS or FSS scores.
Secondary benefits
- Sustained reduction in perceived fatigue (Van Kessel 2009; Moss-Morris, 2012; Phyo 2018; Henry 2024).
- Improved stress coping strategies (Thomas, 2006).
- Improved adjustment to the illness (Thomas, 2006).
- Reduction in stress-related hospitalizations (Mohr 2001).
- Improved social functioning
- Improvement in migraine symptoms in some patients (Thevar 2025)
- Improved medication adherence, where applicable.
- Improved quality of life (Moss-Morris 2013).
- Improved stress coping strategies (Thomas, 2006).
- Improved adjustment to the illness (Thomas, 2006).
- Reduction in stress-related hospitalizations (Mohr 2001).
- Improved social functioning
- Improvement in migraine symptoms in some patients (Thevar 2025)
- Improved medication adherence, where applicable.
- Improved quality of life (Moss-Morris 2013).
Direct Risks
A temporary increase in emotional distress during cognitive exposure.
Risks of interaction
No adverse effects have been observed with long-term treatments for multiple sclerosis.
Biological and Psychosocial Mechanisms
- Reduction in negative cognitive biases (Moss-Morris, 2013).
- Increase in active coping strategies and decrease in rumination (Mohr, 2001). Improvement in self-efficacy and emotional regulation.
- Acceptance of the illness and reduction of embarrassing behaviors through NMI influence anxiety-depressive disorders (Goldsmith 2020).
- Changes in beliefs regarding emotion management through NMI have a mediating effect on functional disability.
- Neurobiologically, modulation of brain circuits (prefrontal cortex and amygdala), increased neural plasticity, and reduced stress-related inflammation.
- Cognitively, restructuring of catastrophic thoughts, reduction in rumination, and development of a sense of self-efficacy.
- Behaviorally, behavioral activation through resuming enjoyable activities, gradual exposure to anxiety-provoking situations, improved pacing, and improved sleep hygiene with reduced nocturnal hypervigilance.
- Emotionally: learning emotional regulation, relaxation, breathing, and mindfulness (Goldsmith 2020).
- Socially: developing communication skills, assertiveness, and better management of uncertainty.
Responding population
Adults with multiple sclerosis experiencing mild to moderate psychological distress.
Nonresponding population
Severe cognitive impairments that prevent active participation.
Unstabilized psychotic disorders.
Unstabilized psychotic disorders.
Participants
Individual
Duration
10 weeks
Sessions per week
1 session per week
Procedure
The cognitive-behavioral therapy protocol takes into account the specific characteristics of multiple sclerosis, namely chronic fatigue, uncertainty about the disease’s progression, pain, and the perceived loss of control.
Session 1: Assessment and Psychoeducation
Objective: To understand the link between multiple sclerosis, anxiety, depression, and fatigue. To set personalized goals. Content: Introduction to the cognitive-behavioral model; explanation of vicious cycles (rumination, avoidance, isolation). Homework: Keep a daily journal (mood, fatigue, thoughts, activities).
Session 2: Identifying Automatic Thoughts
Objective: Become aware of negative thoughts related to the disease. Content: Introduction to the thought log; distinguishing between facts and interpretations. Homework: Write down 3 anxiety-provoking or depressive situations along with the associated thoughts.
Session 3: Cognitive Restructuring (1)
Objective: Learn to challenge catastrophic thoughts. Content: Common cognitive distortions (catastrophizing, overgeneralization, mind reading). Homework: For each thought you wrote down, write a more realistic alternative.
Session 4: Cognitive Restructuring (2)
Objective: To deepen cognitive flexibility. Content: “Thought Court” techniques, Socratic dialogue, self-compassion. Homework: Choose a recurring thought and apply the “pros and cons” method.
Session 5: Behavioral Activation
Objective: To combat isolation and loss of motivation. Content: Identifying abandoned activities; planning enjoyable and rewarding activities. Homework: Schedule two enjoyable activities during the week (even small ones).
Session 6: Anxiety and Stress Management
Objective: To reduce hypervigilance and anxiety. Content: Progressive muscle relaxation, abdominal breathing, introduction to mindfulness. Homework: Practice 10 minutes of relaxation or meditation every day.
Session 7: Managing Fatigue and Daily Rhythm
Objective: Learn to manage MS specific fatigue. Content: Psychoeducation on fatigue, pacing techniques (balancing activity and rest), planning a realistic schedule. Homework: Keep an energy/activity log to identify optimal times.
Session 8: Assertiveness and Communication
Objective: To improve communication with family, friends, and caregivers. Content: Assertiveness techniques, role-playing, learning to express needs without guilt. Homework: Practice making an assertive request during the week.
Session 9: Consolidating Gains
Objective: To reinforce acquired skills and adjust strategies. Content: Review of tools (thought journal, relaxation, activity planning). Homework: Choose two favorite tools and use them daily.
Session 10: Relapse Prevention
Objective: Maintain progress and anticipate future difficulties. Content: Identify warning signs (rumination, isolation, excessive fatigue); develop a personalized action plan. Homework: Create your “psychological survival kit” (strategies, resources, support people).
Session 1: Assessment and Psychoeducation
Objective: To understand the link between multiple sclerosis, anxiety, depression, and fatigue. To set personalized goals. Content: Introduction to the cognitive-behavioral model; explanation of vicious cycles (rumination, avoidance, isolation). Homework: Keep a daily journal (mood, fatigue, thoughts, activities).
Session 2: Identifying Automatic Thoughts
Objective: Become aware of negative thoughts related to the disease. Content: Introduction to the thought log; distinguishing between facts and interpretations. Homework: Write down 3 anxiety-provoking or depressive situations along with the associated thoughts.
Session 3: Cognitive Restructuring (1)
Objective: Learn to challenge catastrophic thoughts. Content: Common cognitive distortions (catastrophizing, overgeneralization, mind reading). Homework: For each thought you wrote down, write a more realistic alternative.
Session 4: Cognitive Restructuring (2)
Objective: To deepen cognitive flexibility. Content: “Thought Court” techniques, Socratic dialogue, self-compassion. Homework: Choose a recurring thought and apply the “pros and cons” method.
Session 5: Behavioral Activation
Objective: To combat isolation and loss of motivation. Content: Identifying abandoned activities; planning enjoyable and rewarding activities. Homework: Schedule two enjoyable activities during the week (even small ones).
Session 6: Anxiety and Stress Management
Objective: To reduce hypervigilance and anxiety. Content: Progressive muscle relaxation, abdominal breathing, introduction to mindfulness. Homework: Practice 10 minutes of relaxation or meditation every day.
Session 7: Managing Fatigue and Daily Rhythm
Objective: Learn to manage MS specific fatigue. Content: Psychoeducation on fatigue, pacing techniques (balancing activity and rest), planning a realistic schedule. Homework: Keep an energy/activity log to identify optimal times.
Session 8: Assertiveness and Communication
Objective: To improve communication with family, friends, and caregivers. Content: Assertiveness techniques, role-playing, learning to express needs without guilt. Homework: Practice making an assertive request during the week.
Session 9: Consolidating Gains
Objective: To reinforce acquired skills and adjust strategies. Content: Review of tools (thought journal, relaxation, activity planning). Homework: Choose two favorite tools and use them daily.
Session 10: Relapse Prevention
Objective: Maintain progress and anticipate future difficulties. Content: Identify warning signs (rumination, isolation, excessive fatigue); develop a personalized action plan. Homework: Create your “psychological survival kit” (strategies, resources, support people).
Components
- Cognitive restructuring.
- Behavioral exercises.
- Relaxation and breathing exercises.
- Self-monitoring and thought records.
Equipment
- Self-reflection journal.
- Relaxation audio recordings.
- Practical guides.
Location
Psychology practice.
Multidisciplinary health center.
Hospital specializing in multiple sclerosis.
Teleconsultations available.
Multidisciplinary health center.
Hospital specializing in multiple sclerosis.
Teleconsultations available.
Best implementation practices
- Adjust the pace to account for fatigue caused by the illness.
- Foster a strong therapeutic alliance.
- Involve the family as needed to support adherence.
- Use simplified written materials in cases of mild cognitive impairment.
- Foster a strong therapeutic alliance.
- Involve the family as needed to support adherence.
- Use simplified written materials in cases of mild cognitive impairment.
Best practices for sustainability
- Encourage patients to practice cognitive restructuring exercises on their own.
- Offer monthly follow-up sessions.
- Integrate CBT into a multidisciplinary care plan.
- Offer monthly follow-up sessions.
- Integrate CBT into a multidisciplinary care plan.
Precautions
- Indicate your level of fatigue before each session.
- Precautions to take in the event of active relapses of multiple sclerosis.
- Report any new or increased emotions during exposure exercises.
- Precautions to take in the event of active relapses of multiple sclerosis.
- Report any new or increased emotions during exposure exercises.
Regulatory specification
This practice is reserved for trained clinical psychologists and psychiatrists.
Main Initiator
Aaron T. Beck, University of Pennsylvania, États-Unis.
Qualification required
Clinical psychologist trained in CBT.
Psychiatrist trained in CBT.
Psychiatrist trained in CBT.
References
Prototype study
Van Kessel K et al. A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue. Psychosom Med. 2008 Feb;70(2):205-13. https://doi.org/10.1097/PSY.0b013e3181643065
Mechanistic study
Goldsmith K, Hudson JL, Chalder T, Dennison L, Moss-Morris R. How and for whom does supportive adjustment to multiple sclerosis cognitive-behavioural therapy work? A mediated moderation analysis. Behav Res Ther. 2020 May;128:103594. https://doi.org/10.1016/j.brat.2020.103594
Interventional studies
Mohr DC et al. Treatment of depression in multiple sclerosis with psychotherapy or sertraline: A randomized controlled trial. J Consult Clin Psychol. 2001;69(6):942-949. https://doi.org/10.1037/0022-006X.69.6.942
Moss-Morris R et al. A randomized controlled trial of cognitive behavioral therapy (CBT) for adjusting to multiple sclerosis (the saMS trial): does CBT work and for whom does it work? J Consult Clin Psychol. 2013 Apr;81(2):251-62. https://doi.org/10.1037/a0029132
Implementation study in Europe
Gay MC et al. Long-term effectiveness of a cognitive behavioural therapy (CBT) in the management of fatigue in patients with relapsing remitting multiple sclerosis (RRMS): a multicentre, randomised, open-label, controlled trial versus standard care. J Neurol Neurosurg Psychiatry. 2024 Jan 11;95(2):158-166. https://doi.org/10.1136/jnnp-2023-331537
Other publications
Abbie L et al. The efficacy of cognitive behavioural therapy for depression and anxiety in multiple sclerosis: A systematic review and meta-analysis. Multiple Sclerosis and Related Disorders 2024: 91; 105858. https://doi.org/10.1016/j.msard.2024.105858
Bruno A et al. Investigating depression in multiple sclerosis: an Italian Delphi consensus on clinical manifestations, diagnosis and treatment. Front Psychiatry. 2025 Jun 30;16:1557335. https://doi.org/10.3389/fpsyt.2025.1557335
Gay MC et al. Long-term effectiveness of a cognitive behavioural therapy (CBT) in the management of fatigue in patients with relapsing remitting multiple sclerosis (RRMS): a multicentre, randomised, open-label, controlled trial versus standard care. J Neurol Neurosurg Psychiatry. 2024 Jan 11;95(2):158-166. https://doi.org/10.1136/jnnp-2023-331537
Gold MG et al. Internet-delivered cognitive behavioural therapy programme to reduce depressive symptoms in patients with multiple sclerosis: a multicentre, randomised, controlled, phase 3 trial. The Lancet Digital Health 2023:5,10:e668-e678. https://doi.org/10.1016/S2589-7500(23)00109-7
Henry LT et al. Cognitive behavioural therapy for fatigue in patients with multiple sclerosis: A systematic review and meta-analysis. Multiple Sclerosis and Related Disorders. 2024, 91: 105908. https://doi.org/10.1016/j.msard.2024.105908
Hind D et al. Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: A systematic review and meta-analysis. BMC Psychiatry. 2014;14:5. https://doi.org/10.1186/1471-244X-14-5
National Institute for Health and Care Excellence. Multiple sclerosis in adults: management. NICE guideline [NG220]. 2022. https://www.nice.org.uk/guidance/ng220
Phyo AZZ et al. The Efficacy of Psychological Interventions for Managing Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Front Neurol. 2018 Apr 4;9:149. https://doi.org/10.3389/fneur.2018.00149
Scandiffio J et al. Effects of psychological therapies in people with multiple sclerosis: a systematic review and network meta-analysis of randomized controlled trials. J Neurol. 2025 Aug 20;272(9):584. https://doi.org/10.1007/s00415-025-13315-6
Thevar P, Wong D, Hutton E, Alpitsis R, Malpas C, McIlroy A. Cognitive behaviour therapy tailored to migraine in multiple sclerosis: A pilot randomized controlled trial. Neuropsychol Rehabil. 2025 Aug 20:1-25. https://doi.org/10.1080/09602011.2025.2545303
Van Kessel K et al. A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue. Psychosom Med. 2008 Feb;70(2):205-13. https://doi.org/10.1097/PSY.0b013e3181643065
Mechanistic study
Goldsmith K, Hudson JL, Chalder T, Dennison L, Moss-Morris R. How and for whom does supportive adjustment to multiple sclerosis cognitive-behavioural therapy work? A mediated moderation analysis. Behav Res Ther. 2020 May;128:103594. https://doi.org/10.1016/j.brat.2020.103594
Interventional studies
Mohr DC et al. Treatment of depression in multiple sclerosis with psychotherapy or sertraline: A randomized controlled trial. J Consult Clin Psychol. 2001;69(6):942-949. https://doi.org/10.1037/0022-006X.69.6.942
Moss-Morris R et al. A randomized controlled trial of cognitive behavioral therapy (CBT) for adjusting to multiple sclerosis (the saMS trial): does CBT work and for whom does it work? J Consult Clin Psychol. 2013 Apr;81(2):251-62. https://doi.org/10.1037/a0029132
Implementation study in Europe
Gay MC et al. Long-term effectiveness of a cognitive behavioural therapy (CBT) in the management of fatigue in patients with relapsing remitting multiple sclerosis (RRMS): a multicentre, randomised, open-label, controlled trial versus standard care. J Neurol Neurosurg Psychiatry. 2024 Jan 11;95(2):158-166. https://doi.org/10.1136/jnnp-2023-331537
Other publications
Abbie L et al. The efficacy of cognitive behavioural therapy for depression and anxiety in multiple sclerosis: A systematic review and meta-analysis. Multiple Sclerosis and Related Disorders 2024: 91; 105858. https://doi.org/10.1016/j.msard.2024.105858
Bruno A et al. Investigating depression in multiple sclerosis: an Italian Delphi consensus on clinical manifestations, diagnosis and treatment. Front Psychiatry. 2025 Jun 30;16:1557335. https://doi.org/10.3389/fpsyt.2025.1557335
Gay MC et al. Long-term effectiveness of a cognitive behavioural therapy (CBT) in the management of fatigue in patients with relapsing remitting multiple sclerosis (RRMS): a multicentre, randomised, open-label, controlled trial versus standard care. J Neurol Neurosurg Psychiatry. 2024 Jan 11;95(2):158-166. https://doi.org/10.1136/jnnp-2023-331537
Gold MG et al. Internet-delivered cognitive behavioural therapy programme to reduce depressive symptoms in patients with multiple sclerosis: a multicentre, randomised, controlled, phase 3 trial. The Lancet Digital Health 2023:5,10:e668-e678. https://doi.org/10.1016/S2589-7500(23)00109-7
Henry LT et al. Cognitive behavioural therapy for fatigue in patients with multiple sclerosis: A systematic review and meta-analysis. Multiple Sclerosis and Related Disorders. 2024, 91: 105908. https://doi.org/10.1016/j.msard.2024.105908
Hind D et al. Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: A systematic review and meta-analysis. BMC Psychiatry. 2014;14:5. https://doi.org/10.1186/1471-244X-14-5
National Institute for Health and Care Excellence. Multiple sclerosis in adults: management. NICE guideline [NG220]. 2022. https://www.nice.org.uk/guidance/ng220
Phyo AZZ et al. The Efficacy of Psychological Interventions for Managing Fatigue in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Front Neurol. 2018 Apr 4;9:149. https://doi.org/10.3389/fneur.2018.00149
Scandiffio J et al. Effects of psychological therapies in people with multiple sclerosis: a systematic review and network meta-analysis of randomized controlled trials. J Neurol. 2025 Aug 20;272(9):584. https://doi.org/10.1007/s00415-025-13315-6
Thevar P, Wong D, Hutton E, Alpitsis R, Malpas C, McIlroy A. Cognitive behaviour therapy tailored to migraine in multiple sclerosis: A pilot randomized controlled trial. Neuropsychol Rehabil. 2025 Aug 20:1-25. https://doi.org/10.1080/09602011.2025.2545303
Experts who voted for the publication of this sheet
NINOT Grégory , FEGER Céline , CALONE MichèleAuthor(s) of the Sheet
NPIS (comité scientifique)
Creation Date : 13/03/2026
Revision Date : 01/04/2026
Version : V01
Revision Date : 01/04/2026
Version : V01
Download the sheet in PDF format
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